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Terms and Policy

Guidelines for Licensed Professional Counselors specify privacy
rules for patient records. New HIPPA regulations protect
virtually all patients regardless of where they live or where
they receive their health care. Every time you see a physician,
are admitted to the hospital, fill a prescription, or send a
claim to a health plan, your health care provider will need to
consider the privacy rule. All health information including paper
records, oral communications, and electronic formats (such as
email) are protected by the privacy rule.

The privacy rule also provides you certain rights, such as the
right to have access to your medical records. However, there are
exceptions; these rights are not absolute. I also take
precautions to safeguard your health information such as
employing computer security measures. Please feel free to ask
questions about exercising your rights or how your health
information is protected.

NOTICE OF PRIVACY POLICIES

Your Information. Your Rights. Our Responsibilities.
This notice describes how medical information about you may be
used and disclosed and how you can get access to this
information. Please review it carefully.
Your Rights
You have the right to:
- Get a copy of your paper or electronic medical record
- Correct your paper or electronic medical record
- Request confidential communication
- Ask us to limit the information we share
- Get a list of those with whom we've shared your information
- Get a copy of this privacy notice
- Choose someone to act for you
- File a complaint if you believe your privacy rights have been
violated
Your Choices
You have some choices in the way that we use and share
information as we:
- Tell family and friends about your condition
- Provide disaster relief
- Include you in a hospital directory
- Provide mental health care
- Market our services and sell your information
- Raise funds

Our Uses and Disclosures
We may use and share your information as we:
- Treat you
- Run our organization
- Bill for your services
- Help with public health and safety issues
- Comply with the law
- Address workers' compensation, law enforcement, and other
government
requests
- Respond to lawsuits and legal actions
Your Rights
When it comes to your health information, you have certain
rights. This section explains your rights and some of our
responsibilities to help you.
Get an electronic or paper copy of your medical record
- You can ask to see or get an electronic or paper copy of your
medical record and other health information we have about you.
Ask us how to do this.
- We will provide a copy or a summary of your health information,
usually within 30 days of your request. We may charge a
reasonable, cost-based fee.
Ask us to correct your medical record
- You can ask us to correct health information about you that you
think is incorrect or incomplete. Ask us how to do this.
- We may say "no" to your request, but we'll tell you why in
writing within 60 days. Request confidential communications
- You can ask us to contact you in a specific way (for example,
home or office phone) or to send mail to a different address.
- We will say "yes" to all reasonable requests. Ask us to limit
what we use or share
- You can ask us not to use or share certain health information
for treatment, payment, or our operations. We are not required to
agree to your request, and we may say "no" if it would affect
your care.
- If you pay for a service or health care item out-of-pocket in
full, you can ask us not to share that information for the
purpose of payment or our operations with your health insurer. We
will say "yes" unless a law requires us to share that
information.
Get a list of those with whom we've shared information
- You can ask for a list (accounting) of the times we've shared
your health information for six years prior to the date you ask,
who we shared it with, and why.
- We will include all the disclosures except for those about
treatment, payment, and health care operations, and certain other
disclosures (such as any you asked us to make). We'll provide one
accounting a year for free but will charge a reasonable,
cost-based fee if you ask for another one within 12 months.
Get a copy of this privacy notice
You can ask for a paper copy of this notice at any time, even if
you have agreed to receive the notice electronically. We will
provide you with a paper copy promptly.
Choose someone to act for you
- If you have given someone medical power of attorney or if
someone is your legal guardian, that person can exercise your
rights and make choices about your health information.
- We will make sure the person has this authority and can act for
you before we take any action. File a complaint if you feel your
rights are violated
- You can complain if you feel we have violated your rights by
contacting us using the information on page 1.
- You can file a complaint with the U.S. Department of Health and
Human Services Office for Civil Rights by sending a letter to 200
Independence Avenue, S.W., Washington, D.C. 20201, calling 1-
877-696-6775, or visiting
www.hhs.gov/ocr/privacy/hipaa/complaints/.
- We will not retaliate against you for filing a complaint.
Your Choices
For certain health information, you can tell us your choices
about what we share. If you have a clear preference for how we
share your information in the situations described below, talk to
us. Tell us what you want us to do, and we will follow your
instructions.
In these cases, you have both the right and choice to tell us
to:
- Share information with your family, close friends, or others
involved in your care
- Share information in a disaster relief situation
If you are not able to tell us your preference, for example if
you are unconscious, we may go ahead and share your information
if we believe it is in your best interest. We may also share your
information when needed to lessen a serious and imminent threat
to health or safety.
In these cases we never share your information unless you give us
written permission:
- Marketing purposes
- Sale of your information
- Most sharing of psychotherapy notes
Our Uses and Disclosures
How do we typically use or share your health information?
We typically use or share your health information in the
following ways.
Treat you
We can use your health information and share it with other
professionals who are treating you.
Example: A doctor treating you for an injury asks another doctor
about your overall health condition.
Run our organization
We can use and share your health information to run our practice,
improve your care, and contact you when necessary.
Example: We use health information about you to manage your
treatment and services.
Bill for your services
We can use and share your health information to bill and get
payment from health plans or other entities.
Example: We give information about you to your health insurance
plan so it will pay for your services.
How else can we use or share your health information?
We are allowed or required to share your information in other
ways - usually in ways that contribute to the public good, such
as public health and research. We have to meet many conditions in
the law before we can share your information for these purposes.
For more information see:
www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.
Help with public health and safety issues
We can share health information about you for certain situations
such as:
- Preventing disease
- Helping with product recalls
- Reporting adverse reactions to medications
- Reporting suspected abuse, neglect, or domestic violence
- Preventing or reducing a serious threat to anyone's health or
safety

Do research
We can use or share your information for health research.
Comply with the law
We will share information about you if state or federal laws
require it, including with the Department of Health and Human
Services if it wants to see that we're complying with federal
privacy law.
Respond to organ and tissue donation requests
We can share health information about you with organ procurement
organizations.
Work with a medical examiner or funeral director
We can share health information with a coroner, medical examiner,
or funeral director when an individual dies.
Address workers' compensation, law enforcement, and other
government requests
We can use or share health information about you:
- For workers' compensation claims
- For law enforcement purposes or with a law enforcement
official
- With health oversight agencies for activities authorized by
law
- For special government functions such as military, national
security, and presidential protective
services
Respond to lawsuits and legal actions
We can share health information about you in response to a court
or administrative order, or in response to a subpoena.
Our Responsibilities
- We are required by law to maintain the privacy and security of
your protected health information.
- We will let you know promptly if a breach occurs that may have
compromised the privacy or security of your information.
- We must follow the duties and privacy practices described in
this notice and give you a copy of it.
- We will not use or share your information other than as
described here unless you tell us we can in writing. If you tell
us we can, you may change your mind at any time. Let us know in
writing if you change your mind.

The Notice of Privacy Practices is available for review in my
office, and also on my website (www.UptownDallasCounseling.com).
It describes how you can exercise your rights with regard to
protected health information, and how your confidential health
information is protected.

I have had access to the Notice of Privacy Practices and am aware
of my rights.

Electronic Signature of Client or Legal Guardian( Type Full Name )I have read and I agree to the Notice of Privacy Practices

Welcome and thank you for considering Uptown Dallas Counseling
Center ("The Center") for your mental health needs.
This document contains important information about our
professional services and business policies.

Therapist
Holly Scott, MBA, MS, LPC ("the therapist") is a licensed
professional counselor engaged in private practice providing
mental health care services to clients directly. The therapist,
using her knowledge of human development and behavior, will make
observations about situations as well as suggestions for new ways
to approach situations. It will be important for you to explore
your own feelings and thoughts and to try new approaches in order
for change to occur. You may bring other family members to a
therapy session if you feel it would be helpful, or if this is
recommended by your therapist.

Appointments
Appointments are made by calling 214 459 2776, or by emailing
HollyScottPLLC@gmail.com. Please call to cancel or reschedule at
least 24 hours in advance, or you will be charged for the missed
appointment.

Number of Visits
The number of sessions needed depends on many factors and will be
discussed by the therapist. Your initial session will involve an
evaluation of your needs and, depending on your circumstances,
further evaluative sessions may be required. At the end of the
evaluation process Holly Scott, MBA, MS, LPC will be able to
provide you with some first impressions of what therapy may
include and a treatment plan. You should evaluate this
information along with your own opinions of whether you feel
comfortable working with the therapist. Therapy involves a large
commitment of time, money and energy, so you should be very
careful about the therapist you select. If you have questions
about procedures, feel free to discuss them with the therapist at
any time.

Relationship
Your relationship with the therapist is a professional and
therapeutic relationship. In order to preserve this relationship,
it is imperative that the therapist not have any other type of
relationship with you. Personal and/or business relationships
undermine the effectiveness of the therapeutic relationship. The
therapist cares about helping you but is not in a position to be
your friend or to have a social or personal relationship with
you.
If the therapist encounters you in public setting, in order not
to reveal your identity, the therapist will not acknowledge your
presence unless addressed by you client first
.
Gifts, bartering, and trading services are not appropriate and
should not be shared between you and the therapist.

Goals, Purposes and Techniques of Therapy
There may be alternative ways to effectively treat the problems
you are experiencing. It is important for you to discuss any
questions you may have regarding the treatment recommended by the
therapist and to have input into setting the goals of your
therapy. As therapy progresses these goals may change.

Holly Scott, MBA, MS, LPC is a Cognitive Behavioral Therapist.
She has post-graduate training in the field from the Beck
Institute of Cognitive Therapy and New York City Cognitive
Behavior Therapy. If you would like more information on the
efficacy of CBT, please ask your therapist.

Cancellations
Cancellations must be received at least 24 hours before your
scheduled appointment; otherwise you will be charged the session
fee for that missed appointment. You are responsible for calling
to cancel or reschedule your appointment.

Payment for Services
The charge for each 50-minute therapy session is $150.
These fees are subject to change upon sixty (60) day prior notice
to you. The undersigned therapist will look to you for full
payment of your account, and you will be responsible for payment
of all charges at the time services are rendered.

Confidentiality
Discussions between a therapist and a client are confidential. No
information will be released without the client's written consent
unless mandated or permitted by law. Possible exceptions to
confidentiality include but are not limited to the following
situations: child abuse; abuse of the elderly or disabled; abuse
of patients in treatment facilities; sexual exploitation;
AIDS/HIV and other communicable disease infection and possible
transmission; court orders, criminal prosecutions; child custody
cases; suits in which the mental health of a party is in issue;
situations where the therapist has a duty to disclose, or where,
in the therapist's judgment, it is necessary to warn, protect,
notify or disclose; sexual exploitation by a mental health
professional or member of the clergy, fee disputes between the
therapist and the client; a negligence suit brought by the client
against the therapist; the filing of a complaint with a licensing
board or other state or federal regulatory authority; to
regulatory authorities in connection with their compliance or
investigatory responsibilities; to employees or agents of the
practice for operational purposes.

FOR FURTHER INFORMATION REVIEW THE NOTICE OF PRIVACY PRACTICES
FURNISHED TO YOU BY YOUR THERAPIST IN CONJUNCTION WITH THIS
CLIENT INFORMATION AND CONSENT DOCUMENT.

Court Services
In the event the therapist's testimony is requested by you or
required by law, regardless of who is responsible for compelling
the production or testimony, you will be responsible for and
shall pay the costs involved in the hourly rate charged by the
therapist at the time of the request or service of the subpoena,
current rate is $400 per hour, for the time involved in traveling
to and from the testimony location, reviewing records and
preparing to testify, waiting at the location, and in giving
testimony. Such payments are to be made prior to the time the
services are rendered by the therapist. The therapist may require
a deposit for anticipated court appearances and preparation.

After-Hours Emergencies
Please know that your therapist and The Center do not provide
twenty four (24) hour crisis or emergency therapy services.
Should you experience an emergency necessitating immediate mental
health attention, immediately call 911, or if you are able to
safely transport yourself, go to the nearest hospital emergency
room for assistance.

Contacting Your Therapist
Your therapist is often not immediately available by telephone. A
reasonable effort will be made to return any call made during
normal business hours on the same day it is received, weekends
and holidays excepted. Messages left after hours or on weekends
or holidays will normally be returned the next business day.

Email and Text Messages
Holly Scott, MBA, MS, LPC uses and responds to email and text
messages only to arrange or modify appointments. Please do not
send emails related to your treatment or therapy sessions as
electronic communications are not completely secure and
confidential. Any therapy-related questions will not be addressed
by the therapist in any electronic communication, but will be
dealt with during your next therapy session.

Social Media Agreement
I understand that Holly Scott, LPC runs the following
professional Social Media sites: Facebook Page, Twitter Account,
Instagram, Blog, Google+, and LinkedIn account. I further
understand and acknowledge that Holly Scott, LPC does not and
will not provide counseling services by way of the
above-referenced accounts. Public posts are viewable but two-way
communication is not encouraged or desired.

I agree not to attempt to contact Holly Scott by way of any of
these professional Social Media sites.

Therapist's Incapacity or Death
You acknowledge that, in the event the undersigned therapist
becomes incapacitated or dies, it will become necessary for
another therapist to take possession of your file and records. By
signing this information and consent form below, you give consent
to allowing another licensed mental health professional, selected
by the undersigned therapist, to take possession of your file and
records.

Video or Audio Recordings
You acknowledge and, by signing this information and consent form
below, agree that you will not record any part of your sessions,
unless you and the therapist mutually agree in writing that the
session may be recorded. You further acknowledge that the
undersigned therapist objects to you recording any portion of
your sessions with out the therapist's written consent.

Consent to Treatment
I, voluntarily, agree to receive (or agree for my child to
receive) Mental Health care, treatment, or services, and
authorize the undersigned therapist to provide such care,
treatment, or services as are considered necessary and
advisable.

I understand and agree that I will participate in the planning of
my care (or my child's care), treatment, or services, and that I
may stop such care, treatment, or services that I receive (or my
child receives) through the undersigned therapist at any
time.

By signing this Client Information and Consent form, I, the
undersigned client (or parent), acknowledge that I have read,
understood and agreed to be bound by all the terms, conditions
and information it contains. Ample opportunity has been offered
to me to ask questions and seek clarification of anything unclear
to me.

Client/Parent

Electronic Signature of Client or Legal Guardian( Type Full Name )I have read and I agree to the Informed Consent for Treatment